
==== Front
Can J Respir Ther
Can J Respir Ther
3251
Canadian Journal of Respiratory Therapy: CJRT = Revue Canadienne de la Thérapie Respiratoire : RCTR
1205-9838
2368-6820
Canadian Society of Respiratory Therapists Website: Canadian Journal of Respiratory Therapy

38076484
90520
10.29390/001c.90520
Research Article
Impact of telephone follow-up on COPD outcomes in pulmonary rehabilitation patients: A randomized clinical trial
https://orcid.org/0000-0002-1529-6639
Tonguino Rosero Stefanie Conceptualization Data curation Formal Analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 1 2
https://orcid.org/0000-0002-1503-9712
Ávila Valencia Juan Carlos Conceptualization Data curation Formal Analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Visualization Validation Writing – original draft Writing – review & editing 3 4
https://orcid.org/0000-0002-7292-7628
Betancourt Peña Jhonatan Conceptualization Data curation Formal Analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 2 3
1 Health and Rehabilitation Faculty Institución Universitaria Escuela Nacional del Deporte https://ror.org/01wsvqj37
2 Health Faculty Universidad del Valle https://ror.org/02xw8cw23
3 Health and Rehabilitation Faculty Institución Universitaria Escuela Nacional del Deporte https://ror.org/01wsvqj37
4 Cardiac and Pulmonary Rehabilitation Program Clínica de Occidente
Corresponding author: Postal address: 760001. Telephone: (57) 3183400019 E-mail: stefanie.tonguino@endeporte.edu.co Permanent address: Calle 9 34 - 01 Cali-Valle
7 12 2023
2023
59 245255
10 8 2023
24 11 2023
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (4.0) which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background

The educational component is a comprehensive part of Pulmonary Rehabilitation (PR), and telephone follow-up (TFU) is an alternative to reinforce face-to-face education. The objective was to determine the effect of telephone follow-up on educational needs, dyspnea, quality of life and functional capacity in Chronic Obstructive Pulmonary Disease (COPD) patients undergoing PR.

Methods

Double-blind randomized controlled clinical trial in patients with COPD in a PR program in Cali-Colombia, allocation by randomization tables. All patients received 24 sessions of PR, which included face-to-face education sessions. In addition, the experimental group received telephone calls twice a week to reinforce the face-to-face educational content. The Lung Information Needs Questionnaire (LINQ) was used to measure disease knowledge, the Saint George’s Respiratory Questionnaire to measure quality of life, the modified Medical Research Council (mMRC) scale to measure dyspnea, and the 6-minute walking test (6MWT) to measure functional capacity.

Results

Thirty-four patients were randomized and 31 were analyzed. PR group with conventional education (PRTE) n=15 and PR group with education plus telephone follow-up (PRTETFU) n=16. Significant improvement from baseline to endpoint in both groups: LINQ (PRTE 4±1.1, p=0.003, PRTETFU 5.8±10.6, p=0.000), mMRC (PRTE 1.6±0.3, p=0.000, PRTETFU 0.6±0.3, p=0.036) and functional capacity (PM6M: PRTE 45.9m±16.1, p=0.013, PRTETFU 62.8m±21.4, p=0.010). Analysis showed differences between groups for changes in LINQ knowledge domain after intervention, with greater improvement for PRTETFU (p=0.018).

Discussion

The TFU is an alternative to reinforce the education. This study demonstrated greater positive effects for the autonomous management of the pathology.

Conclusion

Adding educational reinforcement through phone calls to patients with COPD during PR leads to improved knowledge and skills for managing the disease.

Health Education
Self Care
Rehabilitation
Lung Diseases
Rehabilitation Centers
Cell Phone Use
Self-Management
This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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pmcIntroduction

Pulmonary rehabilitation (PR) programs often include an educational component. Its purpose is to improve the knowledge and skills of patients and their families for the care and autonomous management of their chronic respiratory pathology and reinforce adherence to physical exercise.1,2 Chronic Obstructive Pulmonary Disease (COPD) is defined by the long-term obstruction of airflow, causing chronic cough, sputum production, dyspnea, and exacerbations.3 Implementing educational interventions in COPD patients has shown significant reductions in the probability of hospital admission for exacerbations, improvement in health-related quality of life (HRQoL), and the perception of dyspnea.4,5

COPD patients who complete PR experience improved exercise tolerance, dyspnea control, and overall quality of life, enabling them to lead a more active lifestyle.5 However, a considerable number of COPD patients fail to complete PR programs, forfeiting the benefits6 and imposing a higher financial burden on healthcare systems.7 Additional tactics, like education, may prove helpful in maintaining the benefits of PR and ensuring compliance with health provider guidance.8

Telephone follow-up (TFU) is a strategy that allows continuous communication with the patient beyond face-to-face encounters and has demonstrated positive effects on adherence to PR treatment.9–12 However, there is limited research studying the effects of including TFU as part of the PR treatment to improve adherence and outcomes.

This study aimed to determine the effect of TFU on educational needs, dyspnea, quality of life, and functional capacity in COPD patients undergoing PR.

Methods

A double-blinded, randomized clinical trial was conducted on patients with COPD who participated in a PR program at a clinic in Cali, Colombia, from February to August 2020.

The clinic’s ethics committee approved this study, adopted all the recommendations of the Declaration of Helsinki and Resolution 008430 of the Colombian Ministry of Health and Social Protection, and was approved by the ethics committee of the National School of Sports (Cali-Colombia) Act #126.01.05.03 / May 12, 2020, and got Clinical Trials code NCT05204498. All participants voluntarily consented by signing the informed consent form.

Inclusion criteria: having a diagnosis of COPD confirmed by post-bronchodilator spirometry and pulmonologist taking into account the Global Initiative for Chronic Obstructive Lung Disease (GOLD) subgroup classification (A, B, C, D)3; being between the ages of 50 and 80 years; starting for the first time and completing the PR program and completing at least 85% of the educational sessions. Exclusion criteria: having experienced worsening cardiovascular and metabolic disease leading to hospital or emergency room visits within the past month. Patients receiving treatment with corticosteroids during the previous month and presenting cognitive impairments that restricted their participation in educational sessions.

The Armitage & Berry formula was chosen to calculate the sample size, allowing determining the sample size to find the difference between two independent means.13 The calculation was made with the following data: precision 1.96, power 0.842, standard deviation 1.23, and magnitude of the expected difference 1.19. The required sample size was 16.78 for each group.

The randomization of patients into the intervention groups was carried out once they had completed their consultation with a specialist physician, who verified the inclusion criteria for admission to PR. The patients were then sent to an external person who used the Microsoft Excel program to list the boxes in a table to which a simple randomization formula was applied. Thus, the patients were registered in numerical order and automatically classified in the group they belonged to according to the randomization. The results were sealed in a manila envelope and delivered to an educator trained in education and TFU, who was not part of the research team and was responsible for making the TFU for participants after the PR sessions. Subsequently, they were assigned the schedule and sessions of the PR. This study was double-blinded from the principal investigator and the health professionals participating in the PR program.

Procedures

A physiotherapist specializing in cardiopulmonary rehabilitation evaluated the participants at the beginning of PR and after eight weeks of intervention.

Sociodemographic and clinical data were collected, such as age, sex, socioeconomic status, marital status, home oxygen use and body mass index (BMI), Forced Vital Capacity (FVC), Forced Expiratory Volume in the first second (FEV1), and the ratio (FEV1/FVC) from spirometry (American Thoracic Society ATS: Standardization of Spirometry).14

The Lung Information Needs Questionnaire (LINQ) was used to assess educational needs and knowledge of the disease. This questionnaire includes 19 questions, 16 closed multiple-choice questions, and three open-ended questions, one related to doubts about the disease and the other two with demographic data. The questions are grouped into six domains. The maximum score obtained is 25 and is related to a greater need for education; the minimum score obtained is 0.15,16

The patients self-administered the HADS (Hospital Anxiety and Depression Scale) questionnaire,17 of which has 14 items divided into two subscales (anxiety and depression), each with seven questions. Scores greater than or equal to 11 points reflect clinical problems, scores between 8 and 10 are considered doubtful or risky, and scores lower than seven are standard.

The modified Medical Research Council (mMRC) dyspnea scale was used, with scores ranging from 0 to 4, where 0 represents the absence of dyspnea except during intense exercise and increases to 4, a score that refers to the presence of dyspnea that prevents the patient from leaving the house or that appears even with activities such as dressing.18

The Saint George’s Respiratory Questionnaire (SGRQ) allowed the evaluation of HRQoL. That questionnaire has 50 questions grouped into three dimensions: symptoms, activity, and impact; scores range from 0 to 100, with values close to 0 indicating better HRQoL.19 A decrease of 4 points means a clinically significant improvement.20

The questionnaires were chosen for their frequent use and familiarity in hospital and non-hospital settings by healthcare professionals and patients.

Functional capacity was measured with the 6-minute walking test (6MWT) using ATS recommendations.21 The best distance covered by the two tests performed was taken, as well as the estimated peak oxygen consumption (VO2e) calculated at VO2e=3.5 ml/kg/min + (velocity m/min × 0.1).22

Pulmonary Rehabilitation Program

The PR program included 24 sessions, carried out three times per week for eight weeks. Each session comprised continuous exercise on a treadmill or ergometric bicycle for 30 minutes, starting at 60% of the VO2e reached in the 6MWT. Progression in intensity was performed using the modified Borg scale, increasing until scores between 3/10 and 5/10 were reached.23 Muscle-strengthening exercises were performed in four series of 12 repetitions, starting at 50% of maximum resistance (MR) and increasing until reaching scores between 3/10 and 5/10. The estimation of the MR was made considering the highest number of times that the patients were able to perform each movement evaluated using the correct technique.24 Exercise sessions lasted 60 minutes.

Patients who had saturation <90% or desaturation ≥ 4 points from baseline saturation during the 6MWT were administered oxygen to maintain SpO2 ≥90% during exercise sessions.23

Educational Program

The control group, called PR plus traditional education (PRTE), received group and individual education by health professionals linked to the PR program on topics related to knowledge of the disease, the importance of quitting smoking, use of inhalers, recognition of warning signs, use of home oxygen, proper nutrition, energy conservation techniques, and home breathing exercises.25 During the PR, each participant received individual education for 30 minutes per week regarding topics as previously mentioned. Additionally, the whole group of participants received 60 minutes of group education per week. Patients could attend in the company of a family member; in these sessions, patients had the opportunity to share their experiences and questions about managing their disease with the other attendees and with the professional in charge who moderated the session and resolved the participants’ concerns.

The intervention group—called PR, traditional education, and educational telephone follow-up (PRTETFU)—received the same intervention as the control group. However, an experienced health professional outside the PR program provided additional education to patients with chronic respiratory disease over the telephone. The calls lasted 10-15 minutes and aimed to complement the topics discussed during the face-to-face PR program. The phone calls were conducted twice weekly between 8:00 a.m. and 11:00 a.m. over eight weeks. To ensure consistency of information delivery, pre-designed scripts were utilized to deliver information on chosen topics to all patients (see Supplementary information).

Statistical Analysis

The information was recorded in Microsoft Office Excel® 2010 and analyzed in the SPSS v24 statistical package. The sociodemographic variables are presented in frequencies and percentages; normality tests were performed for each quantitative variable with the Shapiro-Wilk test, presenting the variables with normal behaviour as mean ± standard deviation and the variables that did not comply with normality as median and interquartile range. A t-test for independent samples was performed to compare the variables between each group before and after. The t-test for related samples was performed to compare differences in means and the Wilcoxon test to compare differences in medians at each group’s end of the PR program; a p-value <0.05 was considered statistically significant.

Results

Eligibility for the clinical trial was assessed in 40 patients referred for PR for six months (February to July 2020). Six patients were excluded because they had previously undergone PR, and 34 patients were enrolled in the trial and randomly assigned to the PRTE and PRTETFU groups. There was a dropout rate of 5.5% (two patients who could not transport themselves to the clinic) in PRTE and 3.1% (one patient who did not complete 85% of the educational sessions) in PRTETFU (Figure 1).

188263 Figure 1. Flow chart of the progress of the randomized clinical trial.

PRTE: Pulmonary rehabilitation plus traditional education; RPTETFU: Pulmonary rehabilitation, traditional education, and educational telephone follow-up.

At the beginning of the study, baseline variables had no significant differences between groups (Table 1). The mean age was 65.5 years (±13.69), primarily men (71%) with a history of smoking (64.5%) and had consulted the emergency department for an increase in symptoms in the last year (83.9%); regarding clinical characteristics, the Tiffeneau Index indicated a mean of 56.5 ±13.0 percent and BMI an average of 25.6 ±4.3 kg/m2, reflecting an overweight population (Table 1).

188264 Table 1. Baseline sociodemographic characteristics of the patients.

VARIABLES	Total (n=31)	PRTE (n=15)	PRTETFU (n=16)	p-value	
Age years, mean (SD)	65.5 (13.7)	70.27 (8.5)	63.81 (9.4)	0.056	
Sexn (%)					
Male	22 (71.0)	13 (86.7)	9 (56.3)	0.142	
Female	9 (29.0)	2 (13.3)	7 (43.8)		
Marital status n (%)					
Stable union	24 (77.4)	12 (80.0)	12 (75.0)	0.923	
Non-stable union	7 (22.6)	3 (20.0)	4 (25.0)		
Socioeconomic status n (%)					
Low	13 (41.9)	4 (26.7)	9 (56.3)	0.192	
Middle	16 (51.6)	9 (60.0)	7 (43.8)		
High	2 (6.5)	2 (13.3)	0 (0.0)		
Smoking habitn (%)					
Ex-smoker	20 (64.5)	12 (80.0)	8 (50.0)	0.171	
Never smoked	11 (35.5)	3 (20.0)	8 (50.0)		
Exposure to wood smoken (%)					
Yes	6 (19.4)	3 (20.0)	3 (18.8)	0.713	
No	25 (80.6)	12 (80.0)	13 (81.3)		
Visits to emergency rooms (last year) n (%)					
Yes	26 (83.9)	10 (66.7)	16 (100.0)	0.042	
No	5 (16.1)	5 (33.3)	0 (0.0)		
Home oxygenn (%)					
Yes	10 (32.3)	7 (46.7)	3 (18.8)	0.202	
No	21 (67.7)	8 (53.3)	13 (81.3)		
Average spirometry (SD)					
% FEV 1	52.3 (20.1)	55.8 (21.0)	48.8 (19.2)	0.318	
% FVC	73.6 (15.7)	70.5 (17.2)	76.7 (14.4)	0.282	
FEV 1/ FVC	56.5 (13.0)	60.2 (10.9)	52.8 (15.5)	0.246	
SD: standard deviation; FEV 1: forced expiratory volume in the first second; FVC: forced vital capacity.

Regarding aerobic capacity, the mean distance travelled in the 6MWT was 349.5m ± 107.5, dyspnea assessment was 3.03 ± 1.02 according to mMRC, and 32.3% had an indication for home oxygen. Patients reported the presence of needs in education with a total score of 11.0 ± 4.1 on the LINQ. In the HADS questionnaire, no anxiety or depression symptomatology was observed, and HRQoL had a mean score of 53.3 ± 17.3 (Table 2).

187785 Table 2. Baseline clinical characteristics of the patients.

VARIABLES	Everyone (n=31)	PRTE (n=15)	PRTETFU (n=16)	p-value	
BMI Kg/m2 mean (SD)	25.6 (4.3)	24.8 (3.3)	26.4 (5.1)	0.321	
6MWT mean (SD)					
Distance, meters	349.5 (107.5)	348.6 (94.3)	350.3 (121.7)	0.966	
VO2e, mlO2/kg/min	9.4 (1.8)	9.3 (1.6)	9.4 (2.0)	0.984	
Starting heart rate, bpm	83.9 (14.7)	83.7 (11.5)	84.1 (17.6)	0.942	
Final heart rate, bpm	110.9 (21.8)	113.7 (20.4)	108.3 (23.4)	0.499	
mMRC score, mean (SD)	3.0 (1.0)	3.3 (0.9)	2.8 (1.1)	0.219	
HADS score, mean (SD)					
Anxiety	5.1 (4.0)	4.1 (3.9)	5.9 (4.1)	0.219	
Depression	4.5 (3.9)	3.5 (2.6)	5.4 (4.7)	0.175	
SGRQ score, mean (SD)					
Symptoms	55.9 (22.3)	62.3 (21.9)	49.9 (21.8)	0.125	
Activity	53.9 (23.7)	45.4 (21.3)	61.8 (23.7)	0.053	
Impact	42.1 (18.5)	39.1 (18.5)	44.8 (18.8)	0.402	
Total	53.3 (17.3)	53.2 (20.0)	53.3 (15.1)	0.986	
LINQ score, media (SD)					
Knowledge	2.5 (1.2)	2.5 (1.3)	2.6 (1.2)	0.830	
Medicines	1.2 (1.1)	1.1 (1.3)	1.3 (0.9)	0.769	
Self-care	3.1 (1.8)	3.1 (2.3)	3.1 (1.1)	0.995	
Exercise	2.8 (1.3)	3.0 (1.3)	2.6 (1.4)	0.432	
Diet	1.31 (0.1)	1.3 (0.7)	1.4 (0.8)	0.694	
Smoking	0.1 (0.3)	0.1 (0.4)	0.1 (0.3)	0.521	
Total	11.0 (4.1)	11.1 (5.2)	10.9 (2.9)	0.933	
SD: standard deviation; VO2e: estimated peak oxygen consumption; BMI: body mass index; 6MWT: 6-minute walk test; bpm: beats per minute: mMRC: modified Medical Research Council Dyspnea Scale; HADS: Hospital Anxiety and Depression Scale; SGRQ: St George Respiratory Questionnaire; LINQ: Lung information needs questionnaire.

There were significant improvements in the experimental group (PRTETFU) in all LINQ domains (knowledge p=0.001, medications p=0.006, self-care p=0.000, exercise p=0.005, diet p=0.048, and total score p=0.000) except in the smoking domain score. Similarly, there were improvements in distance travelled in the 6MWT with an increase of 62.8m ± 21.4 (p=0.010), and in dyspnea score, a decrease of 0.6 points ±0.3 (p=0.036). Regarding HRQoL, there was a statistically significant improvement in the activity domain (p=0.004) and clinically significant improvements for the remaining domains (symptoms and impact) and the SGRQ total score (Table 3).

In the control group (PRTE), there were significant improvements for the LINQ in the total score (p=0.003) and in only one of the domains, which was exercise (p=0.000). Likewise, greater distance travelled was observed in the 6MWT with an increase of 45.9 meters ± 16.1 (p=0.013) and a reduction in dyspnea score of 1.6 points ± 0.3 (p=0.000). Regarding HRQoL, there were improvements in the domains of symptoms (p=0.000) and impact (p=0.006), and in the SGRQ total score (p=0.004), the activity domain did not show significant improvements; on the contrary, there was a deterioration of 8.3 (±8.1) points (Table 3).

187786 Table 3. Mean difference in primary and secondary outcome measures: Start vs. End of PR for each study group.

	PRTE (n=15)	p-value	PRTETFU (n=16)	p-value	
Primary outcome measures					
					
LINQ score, mean (SD)					
Knowledge	0.3 (0.3)	0.265	1.37 (0.4)	0.001*	
Medicines	0.7 (0.4)	0.086	0.87 (0.3)	0.006*	
Self-care	0.7 (0.6)	0.268	1.62 (0.3)	0.000*	
Exercise	2.0 (0.4)	0.000*	1.50 (0.5)	0.005*	
Diet	0.2 (0.2)	0.424	0.44 (0.2)	0.048*	
Smoking	0.1 (0.1)	0.164	0.00 (0.0)	1.000	
Total	4.0 (1.1)	0.003*	5.81 (0.6)	0.000*	
					
Secondary outcome measures					
					
BMI Kg/m2 mean (SD)	-0.0 (0.3)	0.923	0.04 (0.7)	0.805	
					
6MWT					
Distance, meters	-45.9 (16.1)	0.013*	-62.8 (21.4)	0.010*	
Starting heart rate, bpm	-1.3 (2.3)	0.568	3.1 (2.5)	0.235	
Final heart rate, bpm	-6.7 (2.9)	0.033*	-3.6 (3.6)	0.329	
VO2e, mlO2/kg/min	-0.8 (0.3)	0.014*	-1.0 (0.4)	0.011*	
					
mMRC score, mean (SD)	1.6 (0.3)	0.000*	0.6 (0.3)	0.036*	
					
HADS score, mean (SD)					
Anxiety	0.6 (0.6)	0.352	0.9 (0.9)	0.290	
Depression	0.1 (0.7)	0.848	0.9 (1.2)	0.451	
					
SGRQ score, mean (SD)					
Symptoms	28.4 (4.2)	0.000*	12.5 (6.3)	0.065	
Activity	-8.3 (8.1)	0.319	18.2 (5.3)	0.004*	
Impact	15.9 (4.9)	0.006*	3.9 (6.7)	0.563	
Total	18.3 (5.3)	0.004*	6.1 (4.8)	0.226	
LINQ: Lung information needs questionnaire; SD: standard deviation; BMI: body mass index; 6MWT: 6-minute walk test; bpm: beats per minute; VO2e: estimated peak oxygen consumption; mMRC: modified Medical Research Council Dyspnea Scale; HADS: Hospital Anxiety and Depression Scale; SGRQ: St George Respiratory Questionnaire; *: p-value < 0.05; p-value (paired samples t-test for equality of variances).

At the end of the study, a statistically significant improvement was found in the LINQ knowledge domain score in favour of the PRTETFU patients. Significant differences were found in the SGRQ impact domain while the remaining outcome measures were analyzed. The control group (PRTE) scored 23.3 points lower (±16.3) compared to the experimental group (PRTETFU), which scored 40.9 points higher (±23.1) with a p-value of 0.021 (Table 4).

187787 Table 4. Differences between groups in primary and secondary outcomes at the end of PR.

	PRTE (n=15)	PRTETFU (n=16)	Mean difference	p-value	
Primary outcome measures					
					
LINQ score, mean (SD)					
Knowledge	2.11 (1.2)	1.2 (0.9)	0.9 (0.4)	0.018*	
Medicines	0.5 (0.7)	0.4 (0.5)	0.1 (0.2)	0.688	
Self-care	2.3 (1.7)	1.4 (1.2)	0.9 (0.5)	0.097	
Exercise	1.0 (1.6)	1.1 (0.9)	-0.1 (0.5)	0.784	
Diet	1.1 (0.8)	0.9 (0.6)	1.1 (0.3)	0.607	
Smoking	0.1 (0.4)	0.1 (0.3)	0.5 (0.1)	0.341	
Total	7.1 (4.0)	5.13 (2.1)	1.9 (1.1)	0.096	
					
Secondary outcome measures					
					
IMC Kg/m2 mean (SD)					
	24.8 (3.1)	26.3 (5.1)	-1.5 (1.5)	0.334	
6MWT mean (SD)					
Distance, meters					
Starting heart rate, bpm	394.5 (94.5)	413.1 (81.3)	-18.6 (31.6)	0.561	
Final heart rate, bpm	85.1 (2.2)	81.1 (11.9)	4.0 (3.7)	0.292	
VO2e, mlO2/kg/min	120.4 (22.7)	111.9 (20.6)	8.5 (7.8)	0.283	
	10.1 (1.6)	10.4 (1.4)	-0.3 (0.5)	0.573	
mMRC score, mean (SD)					
	1.7 (1)	2.2 (1.4)	-0.5 (0.4)	0.237	
HADS score, mean (SD)					
Anxiety					
Depression	3.5 (4.4)	5.3 (3.2)	-1.7 (1.4)	0.228	
	3.4 (3.7)	4.7 (4.4)	-1.3 (1.5)	0.402	
SGRQ score, mean (SD)					
Symptoms					
Activity	33.9 (17.1)	37.4 (25.1)	-3.5 (7.8)	0.655	
Impact	53.7 (21.7)	43.6 (28.2)	10.1 (9.1)	0.274	
Total	23.3 (16.3)	40.9 (23.1)	-17.6 (7.2)	0.021*	
PR: Pulmonary Rehabilitation; LINQ: Lung information needs questionnaire; BMI: Body Mass Index; 6MWT: 6-minute walk test; BPM: beats per minute; VO2e: estimated peak oxygen consumption; mMRC: Modified Medical Research Council Dyspnea Scale; HADS: Hospital Anxiety and Depression Scale; SGRQ: St George Respiratory Questionnaire; *: p-value < 0.05.

Discussion

This study aimed to determine the effect of TFU on educational needs, dyspnea, quality of life, and functional capacity in COPD patients undergoing PR. Our results suggest that an educational component added to aerobic and strength exercises in a PR program improves knowledge, aerobic capacity, dyspnea, and HRQoL for individuals with COPD. Additionally, providing educational support through telephone calls improves patients’ understanding and abilities to manage their illness.

All patients in this study improved their knowledge of their disease and self-care strategies, with significantly better results in the experimental group (PRTETFU). These results align with those previously reported by other researchers.26 For example, García-Aymerich et al. developed self-care educational reinforcement by telephone. They found significant improvements in symptom knowledge (p=0.005) and treatment adherence (p=0.009), with no changes in other measures such as dyspnea, lung function, and HRQoL. Walters et al.,27 also observed improvements in self-care capacity but no impact on HRQoL nor symptoms of anxiety and depression. Nevertheless, the educational interventions proposed by the studies above were developed outside the framework of a PR program.

Other studies have used telephone communication as a strategy to monitor COPD control. Some through daily monitoring technology platforms connected directly to the home telephone,28 monthly telephone follow-ups on symptoms and exacerbations,29 or assignment of individualized comprehensive care plans with telephone reinforcement to ensure adherence.30 Among the most relevant findings are significant improvements in HRQoL,28 health care costs, timely identification of exacerbations, reduction of hospital admissions,29 and recovery time after an exacerbation.30 However, none of these telephone communication strategies were part of a PR program.

The studies that include telephone support during PR are generally for home PR programs or investigate treatment adherence several months after completion. While this study reports similar results regarding adherence to the PR,31 the outcomes from other studies utilizing telephonic support are somewhat contradictory. There were positive impacts in one of the studies: less dyspnea, more exercise tolerance, and improvement in HRQoL in those who received home PR with TFU (p <0.05)32; the opposite was shown in the study by Hornikx et al., in which there were no significant differences in physical activity in patients who had telephone counselling to guide home physical exercise.33 Similarly, regarding the impact of long-term PR, Wong et al. showed that providing telephone support six months after completing PR was no more effective than usual care in maintaining health outcomes, specifically, HRQoL and functional capacity measured with the 6MWT.34 Our study presents unique findings because the telephone guidance stressed the importance of exercising in a planned, organized, and standardized manner rather than just engaging in physical activity to increase energy expenditure.

The most recent systematic review with meta-analysis that evaluated the impact of telephone support on the quality of life and exercise capacity of COPD patients included studies that used telephone calls as a strategy to facilitate adherence, monitor symptoms, achieve disease control after an exacerbation, or support home-based PR. However, none of them investigated telephone follow-up as a strategy to reinforce the educational component provided in a personalized manner during PR. However, none of them investigated telephone follow-up as a strategy to reinforce the educational component provided in a personalized manner during PR, as did our study. The main finding of this meta-analysis is the effect of telephone-based interventions achieving statistically significant improvements in the SGRQ scores (p <0.00001) but not in the 6MWT.35

Regarding HRQoL results, all participants in this study demonstrated improvement on the SGRQ, some domains with statistically significant improvements and others with clinically significant improvements. However, it is noteworthy that the control group (PRTE) showed a deterioration of 8.3 ±8.1 points in the pre- and post-PR activity domain and, on the contrary, significant improvements in the impact domain when comparing the two groups at the end of the study. With regard to these results, it should be noted that it has been shown that the deterioration of HRQOL in COPD is not directly related to the increase in disease severity36 and that the answers to the SGRQ questions are expressions of the patient’s feelings at that moment and therefore may be influenced by his or her mood at the time of assessment,37 which could explain the contradictory results in the PRTE group.

As can be seen up to this point, education for self-management of COPD involves a process that should go beyond providing information, especially if it is considered that due to chronic hypoxemia and hypercapnia, aspects of cognitive capacity such as information processing, concentration, and memory are affected in these patients.38,39 Thus, including the use of strategies that effectively reinforce the message of self-management and that allow continuous communication with the patient beyond the PR session through technological tools or telephone calls, as in the case of the present study, are key to achieving better results in the management of COPD patients.

Although the results are interesting, it is essential to mention that the population was confined due to the COVID-19 pandemic in Colombia in March 2020. This fact limited the involvement of a larger population and could, to some extent, affect the perception of quality of life and mental and cognitive health status in some patients not considered for this study. In turn, the results cannot be generalized to the context of all PR programs. For further research, it is recommended to evaluate the long-term impact to identify whether the effects of the intervention can be sustained over time or if reinforcement of the education component is necessary as time passes. Additionally, the findings of this study could serve as a valuable contribution to developing educational strategies for younger patients within the context of PR programs.

Despite the limitations, our results show a significant improvement in knowledge for autonomous COPD management using an additional TFU during PR. Using a TFU is a simple and inexpensive procedure that can be easily replicated in other rehabilitation centers.

Conclusions

Education about the self-care of patients with chronic respiratory diseases should be an integral part of any PR program. This study suggests that the educational component provided in person during pulmonary rehabilitation can be reinforced through TFU with more significant results in knowledge and skills for the management of their pathology.

Competing interests

The authors have no conflicts of interest to declare.

Contributors

All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. All authors were involved in drafting and commenting on the paper and have approved the final version.

Ethical statement

The study was approved by the ethics committee of the National School of Sports (Cali-Colombia) Act #126.01.05.03 / May 12, 2020, Clinical Trials code NCT05204498.

AI statement

The authors confirm no generative AI or AI-assisted technology was used to generate content.

Supplementary Material

Supplementary Information
==== Refs
Knowledge gaps in patients with COPD and their proxies BMC Pulmonary Medicine Nakken Nienke Janssen Daisy J. A. van den Bogaart Esther H. A. Muris Jean W. M. Vercoulen Jan H. Custers Frank L. Bootsma Gerben P. Gronenschild Michiel H. M. Wouters Emiel F. M. Spruit Martijn A. 30 10 2017
17 1 136 1471-2466 10.1186/s12890-017-0481-8 10.1186/s12890-017-0481-8 29084521
Pilot Study. Changes in the Score of the Lung Information Needs Questionnaire (LINQ) After an Educational Intervention in Patients with Chronic Respiratory Disease Revista Ciencias de la Salud Rosero-Carvajal Hamilton Elias Cuero-Campaz Diego Fernando Arias-Balanta Álvaro Javier Wilches-Luna Esther Cecilia 2 6 2017
15 2 259 272 2145-4507 10.12804/revistas.urosario.edu.co/revsalud/a.5762 10.12804/revistas.urosario.edu.co/revsalud/a.5762
Global Strategy for the Diagnosis, Management and Prevention of COPD - Global Initiative for Chronic Obstructive LungDisease – G (Global Strategy for the Diagnosis, Management and Prevention of COPD - Global Initiative for Chronic Obstructive LungDisease - GOLD 2022
http://goldcopd.org
Self-management education for patients with chronic obstructive pulmonary disease Cochrane Database Syst Rev Effing Tanja Monninkhof Evelyn .M van der Valk Paul P.D.L.P.M. Zielhuis Gerhard GA Walters E. Haydn van der Palen Job J Zwerink Marlies 17 10 2007
4 CD002990 10.1002/14651858.cd002990.pub2 10.1002/14651858.cd002990.pub2
Educational programmes in COPD management interventions: a systematic review Respiratory Medicine Stoilkova Ana Janssen Daisy J.A. Wouters Emiel F.M. 11 2013
107 11 1637 1650 0954-6111 10.1016/j.rmed.2013.08.006 10.1016/j.rmed.2013.08.006
Adherence to Pulmonary Rehabilitation in COPD: A QUALITATIVE EXPLORATION OF PATIENT PERSPECTIVES ON BARRIERS AND FACILITATORS J Cardiopulm Rehabil Prev Oates Gabriela R. Niranjan Soumya J. Ott Corilyn Scarinci Isabel C. Schumann Christopher Parekh Trisha Dransfield Mark T. 9 2019
39 5 344 349 1932-7501 10.1097/hcr.0000000000000436 10.1097/hcr.0000000000000436 31348127
Cost-effectiveness of Pulmonary Rehabilitation Among US Adults With Chronic Obstructive Pulmonary Disease JAMA Network Open Mosher Christopher L. Nanna Michael G. Jawitz Oliver K. Raman Vignesh Farrow Norma E. Aleem Samia Casaburi Richard MacIntyre Neil R. Palmer Scott M. Myers Evan R. American Medical Association (AMA) 22 6 2022
5 6 e2218189 2574-3805 10.1001/jamanetworkopen.2022.18189 10.1001/jamanetworkopen.2022.18189 35731514
Adherence to Pulmonary Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease (COPD) Journal of Respiration Betancourt-Peña Jhonatan Ávila-Valencia Juan Carlos Rodríguez-Castro Jenifer MDPI AG 18 7 2023
3 3 130 140 2673-527X 10.3390/jor3030013 10.3390/jor3030013
A randomized clinical trial of an activity and exercise adherence intervention in chronic pulmonary disease Archives of Physical Medicine and Rehabilitation Steele Bonnie G. Belza Basia Cain Kevin C. Coppersmith Jeff Lakshminarayan Sambasiva Howard JoEllen Haselkorn Jodie K. Elsevier BV 3 2008
89 3 404 412 0003-9993 10.1016/j.apmr.2007.11.003 10.1016/j.apmr.2007.11.003 18295615
Home-based exercise training as maintenance after outpatient pulmonary rehabilitation Respiration du Moulin Marcel Taube Karin Wegscheider Karl Behnke Michaela van den Bussche Hendrik S. Karger AG 31 7 2008
77 2 139 145 0025-7931 10.1159/000150315 10.1159/000150315
Pulmonary rehabilitation: a review of the recent literature Chest Goldstein Roger S. Hill Kylie Brooks Dina Dolmage Thomas E. Elsevier BV 9 2012
142 3 738 749 0012-3692 10.1378/chest.12-0188 10.1378/chest.12-0188 22948578
Making COPD Self-Management Education Work Respiratory Care Becker Ellen A Daedalus Enterprises 25 6 2018
63 7 934 935 0020-1324 10.4187/respcare.06389 10.4187/respcare.06389
Statistical methods in medical research Armitage P. Berry G. Matthews J.N.S. Wiley London 1 2002
9780632052578 10.1002/9780470773666 10.1002/9780470773666
Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement American Journal of Respiratory and Critical Care Medicine Graham Brian L. Steenbruggen Irene Miller Martin R. Barjaktarevic Igor Z. Cooper Brendan G. Hall Graham L. Hallstrand Teal S. Kaminsky David A. McCarthy Kevin McCormack Meredith C. Oropez Cristine E. Rosenfeld Margaret Stanojevic Sanja Swanney Maureen P. Thompson Bruce R. American Thoracic Society 15 10 2019
200 8 e70 e88 1073-449X 10.1164/rccm.201908-1590st 10.1164/rccm.201908-1590st 31613151
Preliminary data from the Lung Information Needs Questionnaire (LINQ) Primary Care Respiratory Journal Jones R.C.M. Hyland M.E. Hanney K.E. 1 10 2005
14 5 270 271 1471-4418 10.1016/j.pcrj.2005.06.008 10.1016/j.pcrj.2005.06.008
Adaptación cultural del cuestionario LINQ (Lung Information Needs Questionnaire) en pacientes con enfermedad respiratoria crónica en un programa de rehabilitación pulmonar en Cali, Colombia Ciencias de la Salud Wilches Esther Cecilia Obregón Lorena Delgado Maria Isabel Rebolledo Diana Fernanda Terreros Adiela 16 1 2014
12 1 23 29 1692-7273 10.12804/revsalud12.1.2014.02 10.12804/revsalud12.1.2014.02
Exactitud y utilidad diagnóstica del Hospital Anxiety and Depression Scale (HAD) en una muestra de sujetos obesos mexicanos Rev Investig Clínica Pascual R.J.S. Barranco J.G. Alvarenga J.C.L. Ovando Á.S. Velázquez V.V Martínez D.A. 2002
54 5 403 409 https://www.imbiomed.com.mx/articulo.php?id=5869
Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease Thorax Bestall J C Paul E A Garrod R Garnham R Jones P W Wedzicha J A BMJ 1 7 1999
54 7 581 586 0040-6376 10.1136/thx.54.7.581 10.1136/thx.54.7.581 10377201
Validity and reliability of the St George's Respiratory Questionnaire after adaptation to a different language and culture: the Spanish example European Respiratory Journal Ferrer M Alonso J Prieto L Plaza V Monso E Marrades R Aguar MC Khalaf A Anto JM European Respiratory Society (ERS) 1 6 1996
9 6 1160 1166 0903-1936 10.1183/09031936.96.09061160 10.1183/09031936.96.09061160
The St George’s Respiratory Questionnaire revisited: a psychometric evaluation Quality of Life Research Paap Muirne C. S. Brouwer Danny Glas Cees A. W. Monninkhof Evelyn M. Forstreuter Benjamin Pieterse Marcel E. van der Palen Job 2015
24 1 67 79 0962-9343 10.1007/s11136-013-0570-y 10.1007/s11136-013-0570-y 24241770
ATS statement: guidelines for the six-minute walk test American Journal of Respiratory and Critical Care Medicine ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories 1 7 2002
166 1 111 117 1073-449X 10.1164/ajrccm.166.1.at1102 10.1164/ajrccm.166.1.at1102
ACSM's Guidelines for Exercise Testing and Prescription American College of Sports Medicine Lippincott Williams & Wilkins 2013

Benefits of pulmonary rehabilitation in patients with COPD with use and without the use of supplemental oxygen during exercise Current Respiratory Medicine Reviews Betancourt-Peña Jhonatan Ávila-Valencia Juan Carlos Assis Jorge Karim Hurtado-Gutiérrez Hugo Benavides-Córdoba Vicente 2019
15 4 281 288 1573-398X 10.2174/1573398x15666191021122926 10.2174/1573398x15666191021122926
Short term and long term effects of pulmonary rehabilitation on physical activity in COPD Respiratory Medicine Egan Claire Deering Brenda M. Blake Catherine Fullen Brona M. McCormack Niamh M. Spruit Martijn A. Costello Richard W. 12 2012
106 12 1671 1679 0954-6111 10.1016/j.rmed.2012.08.016 10.1016/j.rmed.2012.08.016
Benefits of Education in COPD Patients in a Pulmonary Rehabilitation Program Chest del Castillo Nathalie Torres Betancourt-Peña Jhonatan Muñoz-Erazo Beatriz Ávila-Valencia Juan Carlos 10 2017
152 4 A983 0012-3692 10.1016/j.chest.2017.08.1019 10.1016/j.chest.2017.08.1019
Effects of an integrated care intervention on risk factors of COPD readmission Respiratory Medicine Garcia-Aymerich Judith Hernandez Carme Alonso Albert Casas Alejandro Rodriguez-Roisin Robert Anto Josep M. Roca Josep 7 2007
101 7 1462 1469 0954-6111 10.1016/j.rmed.2007.01.012 10.1016/j.rmed.2007.01.012 17339106
Effects of telephone health mentoring in community-recruited chronic obstructive pulmonary disease on self-management capacity, quality of life and psychological morbidity: a randomised controlled trial BMJ Open Walters Julia Cameron-Tucker Helen Wills Karen Schüz Natalie Scott Jenn Robinson Andrew Nelson Mark Turner Paul Wood-Baker Richard Walters E Haydn BMJ 9 2013
3 9 e003097 2044-6055 10.1136/bmjopen-2013-003097 10.1136/bmjopen-2013-003097 24014482
Proactive integrated care improves quality of life in patients with COPD European Respiratory Journal Koff P. B. Jones R. H. Cashman J. M. Voelkel N. F. Vandivier R. W. 7 1 2009
33 5 1031 1038 0903-1936 10.1183/09031936.00063108 10.1183/09031936.00063108
Reduction of hospital utilization in patients with chronic obstructive pulmonary disease: a disease-specific self-management intervention Archives of Internal Medicine Bourbeau Jean Julien M Maltais F. 10 3 2003
163 5 585 591 0003-9926 10.1001/archinte.163.5.585 10.1001/archinte.163.5.585
Effect of an action plan with ongoing support by a case manager on exacerbation-related outcome in patients with COPD: a multicentre randomised controlled trial Thorax Trappenburg J. C. A. Monninkhof E. M. Bourbeau J. Troosters T. Schrijvers A. J. P. Verheij T. J. M. Lammers J.-W. J. BMJ 23 7 2011
66 11 977 984 0040-6376 10.1136/thoraxjnl-2011-200071 10.1136/thoraxjnl-2011-200071
Adherence to Pulmonary Rehabilitation in Patients with Chronic Obstructive Pulmonary Disease (COPD) Journal of Respiration Betancourt-Peña Jhonatan Ávila-Valencia Juan Carlos Rodríguez-Castro Jenifer 18 7 2023
3 3 130 140 2673-527X 10.3390/jor3030013 10.3390/jor3030013
The effects of home-based pulmonary rehabilitation in patients with chronic lung disease International Journal of Nursing Studies Oh Eui-Geum 11 2003
40 8 873 879 0020-7489 10.1016/s0020-7489(03)00071-3 10.1016/s0020-7489(03)00071-3
The effects of a physical activity counseling program after an exacerbation in patients with Chronic Obstructive Pulmonary Disease: a randomized controlled pilot study BMC Pulmonary Medicine Hornikx Miek Demeyer Heleen Camillo Carlos Augusto Janssens Wim Troosters Thierry 4 11 2015
15 1 136 1471-2466 10.1186/s12890-015-0126-8 10.1186/s12890-015-0126-8 26530543
Peer educator vs. respiratory therapist support: which form of support better maintains health and functional outcomes following pulmonary rehabilitation? Patient Education and Counseling Wong Eric Y. Jennings Cally A. Rodgers Wendy M. Selzler Anne-Marie Simmonds Lindsay G. Hamir Rashida Stickland Michael K. 4 2014
95 1 118 125 0738-3991 10.1016/j.pec.2013.12.008 10.1016/j.pec.2013.12.008 24447522
Effects of telephone support on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease: a meta-analysis Psychology, Health & Medicine Deng Nan Gu Ting Zhao Qian Zhang Xiaoyi Zhao Fangfang He Hong 10 1 2018
23 8 917 933 1354-8506 10.1080/13548506.2018.1425462 10.1080/13548506.2018.1425462
Do GOLD stages of COPD severity really correspond to differences in health status? European Respiratory Journal Antonelli-Incalzi R. Imperiale C. Bellia V. Catalano F. Scichilone N. Pistelli R. Rengo F. the SaRA investigators European Respiratory Society (ERS) 9 2003
22 3 444 449 0903-1936 10.1183/09031936.03.00101203 10.1183/09031936.03.00101203 14516133
Comportamiento de la calidad de vida (SGRQ) en pacientes con EPOC según las puntuaciones BODE Archivos de Bronconeumología (English Edition) Nonato Nívia L. Díaz Orlando Nascimento Oliver A. Dreyse Jorge Jardim José R. Lisboa Carmen 7 2015
51 7 315 321 1579-2129 10.1016/j.arbr.2015.04.001 10.1016/j.arbr.2015.04.001
Cognitive impairment in chronic obstructive pulmonary disease--a neuropsychological and spect study Journal of Neurology Antonelli Incalzi Raffaele Marra Camillo Giordano Alessandro Calcagni Maria Lucia Cappa Antonella Basso Salvatore Pagliari Gabriella Fuso Leonello 1 3 2003
250 3 325 332 0340-5354 10.1007/s00415-003-1005-4 10.1007/s00415-003-1005-4
COgnitive-pulmonary disease BioMed Research International Cleutjens Fiona A. H. M. Janssen Daisy J. A. Ponds Rudolf W. H. M. Dijkstra Jeanette B. Wouters Emiel F. M. 2014
2014 697825 1 8 2314-6133 10.1155/2014/697825 10.1155/2014/697825 24738069
